Provider Demographics
NPI:1447423694
Name:GAMBARDELLA, TERESA G (RPH)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:G
Last Name:GAMBARDELLA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 WELLS RD
Mailing Address - Street 2:
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-1506
Mailing Address - Country:US
Mailing Address - Phone:631-368-4098
Mailing Address - Fax:631-261-6371
Practice Address - Street 1:20 WELLS RD
Practice Address - Street 2:
Practice Address - City:GREENLAWN
Practice Address - State:NY
Practice Address - Zip Code:11740-1506
Practice Address - Country:US
Practice Address - Phone:631-368-4098
Practice Address - Fax:631-261-6371
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0044510183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY18350000XMedicaid